Progress Check-In

What is the main injury/issue? *

Are you currently in pain?

YesNoSometimes

If you answered yes to the above, state where you feel the pain

How would you describe the pain? (optional)

If 'Other', describe it (optional)

From 1–10, how intense is the pain?

3

1 · Very Minor10 · Worst imaginable

What makes the pain better

What makes the pain worse?

Is the pain stopping you from any daily activities / movements?

List all the injuries you remember, even ones you think are irrelevant (ex. Concussion, fractures, ligament tears, asthma, vision and balance issues etc.)

Do you feel like you know what happened during the injury? If not, state what you are not sure of / want clarified

Client Intake Form

Injury / Pain History

Goals/Expectations of treatment